Preventing CLABSI

The most important things you need to know about central line associated bloodstream infections (CLABSI).

Overview

Central line associated bloodstream infections (CLABSI) are serious, costly and can result in death. Providers can aim to eliminate CLABSIs by utilizing a specific group of evidence-based practices while inserting and caring for patients with central lines.

On this page:

What is CLABSI?

CLABSI is a laboratory-confirmed primary bloodstream infection associated with a central line (a long fine catheter with an opening at each end used to deliver fluids and drugs) indwelling for more than 48 hours.

Bloodstream infections can occur when bacteria or other pathogens, including fungi, travel down a central line and enter the bloodstream. Infection severity can range from mild to life-threatening.

A CLABSI diagnosis is indicated when the bloodstream infection is not related to an infection from another site.

Who’s at Risk?

The longer a central line is in place, the higher the risk for bloodstream infection – care team members should check in daily to determine if the benefits of continued central line maintenance outweigh the risks of potential CLABSI.

The major types of central venous catheters (CVCs), based on their design, are nontunneled catheters, tunneled catheters, implantable ports, and peripherally inserted central catheters.

Some insertion sites may be more prone to infection such as the femoral vein and internal jugular vein.

Everyone with a central line is
at risk for developing a CLABSI.

The Impact

Central line associated bloodstream infections increase hospital costs, lengthen duration of hospitalization and can result in death. Over the past decade there has been great focus on reducing hospital acquired infections in general and central line associated bloodstream infections in particular.

In 2009, there were approximately 18,000 CLABSIs in ICUs in the United States annually. With a mortality rate as high as 25%, this could represent 4,500 preventable deaths. Since the widespread adoption of safety measures included in the “CLABSI bundle” the incidence of CLABSI has decreased by over 50% since 2001.

Preventing CLABSI in 4 steps:

Think wisely about each central line placement

Remove central lines promptly when no longer needed

When inserting a central line, use techniques known to reduce the risk of infection

While the central line is in place, take precautions to reduce the chance of infection

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Step 1: Think wisely about each central line placement: Does this patient really need a central line?

One of the most effective means of preventing CLABSI is to reduce the use of central venous catheters. There are many indications for central lines including the infusion of vasopressors and inotropes, parenteral nutrition and other caustic medications, and for hemodynamic monitoring.

Finding other means to obtain hemodynamic information (such as using dynamic indices of volume responsiveness or obtaining an echocardiogram) can allow you to avoid placing a central line and putting a patient at risk for developing CLABSI.

2

Step 2: Remove central lines promptly when no longer needed

One of the most effective means of preventing CLABSI is to reduce the use of central venous catheters. There are many indications for central lines including the infusion of vasopressors and inotropes, parenteral nutrition and other caustic medications, and for hemodynamic monitoring.

Finding other means to obtain hemodynamic information (such as using dynamic indices of volume responsiveness or obtaining an echocardiogram) can allow you to avoid placing a central line and putting a patient at risk for developing CLABSI.

3

Step 3: When inserting a central line, use techniques known to reduce the risk of infection (known as an Insertion Bundle):

Select the best site

Practice good hand hygiene

Use maximal-barrier precautions

Use chlorhexidine for skin preparation

4

Step 4: While the central line is in place, take precautions to reduce the chance of infection (known as a Maintenance Bundle):

Daily chlorhexidine bathing

Use a chlorhexidine-soaked sponge dressing

Change the dressing using sterile technique and only when necessary

Change IV tubing frequently

Confirm daily that the central line is still necessary

Ensure that access points are clean when accessing them

Read the landmark paper describing the effectiveness of insertion bundles in preventing CLABSI.

Insertion Bundles:

A few simple precautions can help you make your patient safer when placing a central venous catheter

So simple yet so effective:

In a landmark study involving over 100 ICUs in Michigan, Pronovost and colleagues included five evidence-based practices, including removing unnecessary catheters. Other interventions included: hand hygiene, using full-barrier precautions during central venous catheter insertion, cleansing the skin with chlorhexidine and avoiding the femoral site for central venous catheters when possible. Within three months, they found central line associated blood stream infections were reduced by two-thirds. Furthermore, the rate of CLABSIs were reduced so much they became rare events in the participating ICUs.

Choosing the best site:

Selecting the best site can help reduce the risk of infection. It is generally recommended to avoid the femoral vein when placing a CVC in adults and to preferentially place the catheter in the subclavian vein rather than the internal jugular vein as the subclavian vein has the lowest risk of infection. However, in patients with kidney disease who may require dialysis, it is recommended to avoid the subclavian site. Additionally, subclavian cannulation is associated with an increased risk of pneumothorax – a potentially life-threatening complication. The risks and benefits for each site will have to be accounted for when selecting a cannulation site for any individual patient.

Hand hygiene:

Central line insertion is a sterile procedure and proper hand hygiene should be practiced. The Centers for Disease Control (CDC) recommends either conventional soap and water hand-washing or use of an alcohol-based gel prior to insertion of a CVC.

Maximal-Barrier Precautions:

When placing a central line, several steps should be taken to ensure sterility. These include wearing a hat, mask, sterile gown and sterile gloves and using a full-body sterile drape which completely covers the patient. It is, effectively, a surgical procedure. These steps reduce the likelihood that the catheter could become contaminated during placement.

Chlorhexidine Skin Preparation:

Unless there is a contraindication such as an allergy, chlorhexidine-based skin preparation should be used. It has been shown to have superior efficacy to other agents. In the event that an alternative must be used, the CDC recommends iodine-based agents or 70% alcohol.

Maintenance Bundles:

Simple precautions that can keep a patient with a central line from developing an infection

The Dressing:

Careful attention to how you maintain the dressing which secures a central line in place can help prevent the development of infections. Historically, dressings were changed frequently according to a fixed schedule. However, current practice recommendations suggest that the dressing should only be changed evey seven days unless is it visibly soiled or soaked with blood. A transparent, semi-permeable dressing is best as it allows for daily assessment of the insertion site without the need for removal of the dressing. Sterile gauze is an acceptable alternative (although it is recommended that the dressing be changed every two days if this option is used). Placement of a chlorhexidine-soaked sponge at the catheter insertion site is also recommended to help reduce the rate of CLABSI.

Daily chlorhexidine bathing:

A newer strategy, daily bathing with chlorhexidine, has been shown to help decrease the rate of CLABSI as well as protect patients from other hospital acquired infections, including vancomycin-resistant enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. It is well-tolerated by most patients but should be avoided in patients who have an allergy to chlorhexidine.

Accessing the catheter:

Aseptic technique should be used when accessing any port of a central line or tubing connected to it. This includes practicing hand antisepsis, using clean gloves, and disinfection with 70% alcohol prior to accessing hubs, connectors, or stopcocks. New devices are now available to assist with this step including caps that contain a small alcohol-soaked sponge that can be connected to ports on IV tubing sets to increase compliance.

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